René Bernards

1. MammaPrint, the story of the 70-gene profile René Bernards Professor of Molecular Carcinogenesis The Netherlands Cancer Institute Amsterdam Chief Scientific Officer Agendia Amsterdam

2. The breast cancer treatment dilemma

3. Of 100 women with breast cancer

4. Only 25% will develop distant metastases

5. But we treat over 75% of all patients with chemotherapy

6. Which means that 50% of all breast cancer patients get a toxic chemotherapy that they did not need!

7. Low risk High risk MammaPrint: improved breast cancer diagnosis Low risk High risk

8. Prognosis Reporter Genes Identification of the MammaPrint breast cancer prognosis profile 78 breast tumors (‘83-’94) patients < 55 years lymph node negative no adjuvant therapy Unbiased full genome gene expression analysis distant metastases < 5 years (n=34) no distant metastases in at least 5 years (n=44)

9. MammaPrint Discovery: Van ‘t Veer et al. (2002) Nature 415, 530-536.

10. 70 significant prognosis genes Tumor samples van´t Veer et al., Nature 415, p. 530-536, 2002 MammaPrint prognosis Profile “the 70 gene profile” threshold set at 10% false negatives 91 % sensitivity, 73% specificity

11. proliferation angiogenesis proliferation angiogenesis adhesion to extracellular matrix intravasation, survival, extravasation adhesion to extracellular matrix Genes of unknown function (25) local invasion MammaPrint 70 genes are involved in all aspects of tumor cell biology

12. First validation: • Van de Vijver et al. (2002) • New England J. Med. 347, 1999-2009. 295 patients

13. MammaPrint:Improved Clinical Management Profiling vs St Gallen selection St Gallen MammaPrint MammaPrint improved prediction and more accurate metastases-free metastases-free MammaPrint: 40% in good profile 60 % in poor profile St Gallen: 15% in low risk 85% in high risk NEJM 347, p1999-2009, 2002

14. MammaPrint vs St Gallen guidelines St Gallen MammaPrint Gene profiling: Reduction adjuvant chemotherapy selection Avoiding both over- and undertreatment Improved prognosis prediction NEJM 347, p1999-2009, 2002

15. Second validation: Buyse et al. (2006) JNCI. 98, 1183-1192. 302 patients

16. Independent External Validation:Microarray outperforms all clinical risk assessment Over- treatment! Under- treatment! High clinical risk Adjuvant on line! N=222 73% Low clinical risk Adjuvant on line! N=80 27% 27% microarray Low risk 35% microarray High risk Buyse et al JNCI 2006 >30% Discordant cases!

17. MammaPrint predicts early metastases Time to distant metastasis Hazard Ratios highest in first 5 years JNCI 98, p1183-1192, 2006

18. No effect of Chemotherapy Effect of Chemotherapy Chemotherapy only reduces the early metastases Courtesy: Peter Ravdin

19. High reproducibility of microarray experiments (99%) Reproducibility; repeat of the experiment Reproducibility; 2 samples, 7 month period Glas et al, BMC Genomics 2007

20. MammaPrint: improved breast cancer diagnosis First FDA approved molecular Diagnostic test for cancer 2007 Time Magazine: Invention of the year 2007

21. MINDACT study design 6000 patients, <70 YRS, 1-3 POS NODES ASSESS clinical RISK AND MammaPrint RISK (adjuvant!online & MammaPrint) 10% 55% 35% BOTH HIGH RISK DISCORDANT RISK BOTH LOW RISK RANDOMIZE decision-making Use clinical risk Use MammaPrint low high low high Chemotherapy No chemotherapy

22. Recent additional features of the MammaPrint test:Expanded indications:all ages

23. KM survival curve: Breast cancer > 55 year old 1 Poor Good 0.9 0.8 0.7 0.6 0.5 Survival Probability 0.4 0.3 0.2 0.1 Chi2 = 15.38 P = 8.79e-005(wt power = 0) 0 0 5 10 15 Time(year) MammaPrint prognosis in postmenopausal patients Good prognosis profile Metastases free probability Poor prognosis profile 150 patients Overall survival HR 2.3, 0.95 CI [ 1.3-4.1], p=0.0049

24. Recent additional features of the MammaPrint test:Expanded indications:patients with 1-3 positive lymph nodes

25. Validation of MammaPrint in patients with 1-3 positive lymph nodes • Milan and NKI series 241 patients • Milan EIO (B Viale): 1994-1998 • NKI series: 1984-1995 • 80% treated adjuvant chemo and/or hormonal therapy • Median Follow Up: • Milan: 8.97 years (0-10.9) • NKI : 10.4 years (1.6-21.2)

26. MammaPrint performance in patients with 1-3 positive node(s) • N=241breast cancer patients with 1-3 positive lymph node(s) • Milan & NKI Multivariate HR 6.59 (95% CI 1.71 to 25.45; p = 0.006)

27. Breast cancer with 1-3 positive node(s) MammaPrint Distant metastases as first event Multivariate analysis

28. TargetPrint: Quantification of ER, PR and HER2

29. MammaPrint: extensive regulatory approvals • MammaPrint is the first and only IVDMIA cleared for market by FDA • ISO 17025 accredited and CE mark for European market • CLIA registered to be able to test US patients • CAP Accredited The College of American Pathologists

30. MammaPrint is only the “tip of the iceberg” of personalized medicine Personalized medicine Who needs treatment? Which therapy will work best?

31. Personalized medicine: multiple answers on a single microarray chip Prognosis? Is there a hereditary component? Will tumor respond to Herceptin? Will tumor respond to DNA damaging agents?

32. Poor quality biomolecules: poor quality biomarkers! RNA integrity Protein integrity FFPE Fresh

33. Thank you!